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MEDA - ch 4
The Medical Record
| Term | Definition |
|---|---|
| H & P | history & physical |
| Hx | history |
| CC | chief complaint |
| HPI | history of present illness |
| c/o | complains of |
| Sx | symptom |
| PMH | past medical history |
| UCHD | usual childhood diseases |
| NKA, NKMA, NKDA | no known allergies, no known medicine allergies, no known drug allergies |
| FH | family history |
| SH | social history |
| OH | occupational history |
| ROS | review of systems |
| PE | physical examination |
| HEENT | head, eyes, ears, nose, throat |
| NAD | no acute distress, no appreciable disease |
| PERRLA | pupils equal, round & reactive to light & accommodation |
| WNL | within normal limits |
| Dx | diagnosis |
| IMP | impression |
| A | assessment |
| R/O | rule out |
| P | plan |
| SOAP | subjective, objective, assessment, plan |
| CCU | coronary care unit |
| ER | emergency room |
| ICU | intensive care unit |
| IP | inpatient |
| OR | operating room |
| post-op, postop | postoperative (after surgery) |
| pre-op, preop | preoperative (before surgery) |
| RTC | return to clinic |
| BRP | bathroom privileges |
| CP | chest pain |
| DC, D/C | discharge, discontinue |
| ETOH | ethyl alcohol |
| Tr | treatment |
| Tx | treatment or traction |
| VS | vital signs |
| T | temperature |
| P | pulse |
| R | respiration |
| BP | blood pressure |
| Ht | height |
| Wt | weight |
| yo | year old |
| # | number or pound |
| OP | outpatient |
| prn | as needed |
| acute | sharp; having intense, often severe symptoms and a short course |
| chronic | a condition developing slowly and persisting over time |
| diagnosis | determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings (results) |
| etiology | cause of disease |
| exacerbation | increase in severity of a disease with aggravation of symptoms |
| remission | a period in which symptoms and signs stop or abate |
| febrile | relating to a fever |
| idiopathic | a condition occurring without a clearly identified cause |
| localized | limited to a definite area or part |
| systemic | relating to the whole body rather than only a part |
| malaise | a feeling of unwellness, often the first indication of illness |
| marked | significant |
| morbidity | sick; a state of disease |
| morbidity rate | the number of cases of a disease in a given year; the ratio of sick to well individuals in a given population |
| mortality | a state of being subject to death |
| mortality rate | death rate; ratio of total number of deaths to total number in a given population |
| prognosis | prediction of the likely outcome of a disease based on the general health status of the patient along with knowledge of the usual course of the disease |
| progressive | the advance of a condition as signs and symptoms increase in severity |
| prophylaxis | a process or measure that prevents disease |
| recurrent | to occur again; describes a return of symptoms and signs after a period of quiescence (rest or inactivity) |
| sign | a mark; objectable evidence of disease that can be seen or verified by an examiner |
| symptom | occurance; subjective evidence of disease that is perceived by the patient and often noted in his or her own words |
| syndrome | combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease |
| noncontributory | not involved in bringing on the condition or result |
| unremarkable | not significant or worthy of noting |
Created by:
LCC
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